Tuesday, April 22, 2008

She worked on Saturday. She was by herself for several hours as the other provider overslept and the front desk staff continued to allow walk-ins for hours before he arrived, which was pleasant. She left clinic to catch a flight home for her family's ultra-reform Passover seder (Did the Jews really get kicked out of Egypt 'by management'? If the gentleman with the yarmulke says so!). She flew back to her urban metropolis the following day, her flight delayed by an hour which lead to an 11PM arrival. And then she worked yesterday and saw 30 patients.

So today, for the first time in almost three years, newFNP called in sick when she is, in fact, not sick at all.

Friends, it is everything newFNP imagined it could be.

Early morning bike ride along a scenic route - invigorating! Trip to Korean day spa for a rub and scrub - not for the faint of heart but also invigorating! Sitting on modern Crate & Barrel sofa at 3:30 in the afternoon, sipping cold low-fat chocolate milk - glorious!

While totally off topic, newFNP feels compelled to share some thoughts about the Korean day spa. Not being Korean herself, newFNP's knowledge of Korean culture is limited to her infrequent day spa visits and images of Kim Jong Il on CNN.

What she can deduce from these limited day-spa-related experiences is that for Korean ladies to have dead skin on any part of their bodies - labia included - is verboten. NewFNP is at least 10 pound thinner after having her dead skin scrubbed off by a Korean lady wearing a black bra and panties, all while laying naked on a faux Burberry-patterned, plastic-covered slab in scissor-kick and frog-leg positions in a room full of other naked ladies in similar positions! NewFNP is shiny and pink like a newborn babe and feeling much less self-conscious about her figure flaws.

NewFNP generally feels such guilt about leaving other providers in the lurch, but she knew that there was an extra provider at her site today and she just really, really needed time away from the drab walls and lack of natural light and scabies and uncontrolled DM.

And the best part? Tomorrow is newFNP's day off! Fuck, newFNP is getting giddy just thinking about not having to go back until Thursday. Oh yeah, she is drinking two glasses of wine tonight!

Wednesday, April 16, 2008

Oh, how newFNP fucked herself by not immediately saying "no way, Jose" to her lorazepam seeking patient. Blog commentors, newFNP hears you and acknowledges just how correct you all were. Just when newFNP begins to think that she is no longer so new, something like this happens and newFNP realizes that new has a shitload to do with context.

Of course she came back and of course she wanted more of the sweet, sweet Ativan. This time, newFNP really did need a prn dose to make it through the encounter. Instead, she had to rely on her endogenous adrenalin.

Since she had last seen her, newFNP reviewed this patient's former med records which did not elicit the etiology of either the anxiety or the lorazepam prescription. When newFNP let her patient know this, her patient found this to be an unacceptable obstacle and demanded more pills.

NewFNP said no.

The encounter was one hundred shades of crazy, but involved soap opera-worthy acting, crying, laughing, the patient telling newFNP that the only reason she returned was that she felt like newFNP treated her with respect during the initial encounter (?!?!) and that she wanted to give newFNP a second chance. Thanks. Thanks a million, hon.

NewFNP still doesn't know if she handled this situation correctly, but she does know that if this woman does have a genuine anxiety disorder, Ativan is likely not the optimal choice for primary, long-term treatment and newFNP is not the person to decide what is. NewFNP would just like you all to imagine what the response was to her offer to complete the psychiatry and counseling referrals. Good fucking times, my friends.

NewFNP was mercifully absent from today's all-staff meeting, but her spies expeditiously let her know that the CEO had received some complaints from board members about employees - apparently front desk staff - not treating them well. Being an FQHC, a percentage of our board members are also our clients. While they say that we are not supposed to treat them any differently, that is a big fat lie. The take-home message was that we are all supposed to ramp up our customer service.

NewFNP worries that patients like her lorazepam-seeking patient will complain. She does not want to work in fear of patients who want something that she would be ill-advised to provide. She knows that while some patients are uniformly pleased with her, others are not always satisfied with her service. The clinic is really not set up for provide great customer service and some of the patients really expect more that newFNP or her colleagues can reasonably provide.

Wednesday, April 09, 2008

A huge factor in newFNP's deciding to become an NP was her desire to help people. This is not unique, of course, but sometimes newFNP gets so bogged down in the B.S. of day-to-day clinical life that she sometimes loses sight of this.

But then a patient comes in and reminds newFNP why she's there.

NewFNP has a lovely patient who was diagnosed with metastatic choriocarcinoma after presenting to the ED with weakness and a hemoglobin of 3. After her hospitalization, resection and chemotherapy treatment - which took place at a very fancy-pants hospital - she lost her job of fifteen years and, with it, her health insurance. She was no longer able to get her regular monitoring at the same hospital. Because her tumor was hCG-responsive, she needs to have her hCG checked monthly which is how she ended up at newFNP's clinic about a year ago.

Understandably, when this patient met newFNP, she was also being treated for depression. Cancer, job loss, two young daughters and a precariously employed husband. Yeah, depression and hopelessness seem reasonable.

NewFNP has seen her several times throughout the year for episodic concerns as well as for her monthly monitoring. Generally, she has been physically and emotionally healthy. Today, she finally made it in for her well-woman exam. Like all of newFNP's patients, this patient worries a lot about money, a concern that has become more salient recently. Like all of newFNP's patients, this woman needs insurance. Unlike all of newFNP's patients, she is bilingual and has a social security number and computer skills.

So newFNP did her pap, listened as she cried and disclosed her concerns about financial woes. She would like to restart her anti-depressants. She needs her hCG drawn and the result faxed to the fancy hospitals department of gyn-oncology. She hasn't had the chest x-ray for which newFNP referred her nine months ago because it is just too expensive.

At some point in this encounter, newFNP realized that there has got to be a job somewhere in the five-clinic organization for which newFNP works. This patient certainly would not be the first to transition from patient to employee - three of newFNP's current MAs were former patients at the clinic! NewFNP excused herself after completing the exam and asked her clinic manager if he knew of any openings. In fact, he did. A brand new clinic was looking for an IPA case manager. NewFNP brought him into the room and talk to the patient.

As far as newFNP can see based on an n of one, an IPA case manager works about 50-65% of the time, coordinates fast food restaurant lunch selections 10% of the time, is on the internet 10% of the time and chats with work pals the remaining 15-30% of the time. There is no way that a forty-something year old cancer survivor cannot do better than that!

Today, this patient left our clinic having received a pap, her regular post-choriocarcinoma monitoring, her mammogram referral, her calcium and physical activity recommendations, and with an application for employment and contact name in hand.

And she left with a hope and a smile.

NewFNP knew as she raised the possibility of employment that there was a chance for disappointment. But sometimes we just have to take chances and, dare newFNP say it, have a little faith.

Monday, April 07, 2008

NewFNP is aware that it is wholly within the boundaries of acceptability to discuss one's sex life with one's provider. In newFNP's clinic, however, this discussion generally consists of women telling newFNP that they are tired of having sex with their partners and are stupefied at the amount of sex a man wants. In a 25-patient day, it is exceedingly difficult to suss out if that is because intercourse is physically painful or if it is because their partners are content to sit around and watch TV while the women clean the house & bathe the kids, etc. or if it is because their partners are just sort of remedial when it comes to doing it.

If the aversion stems from physical discomfort, newFNP feels like she can easily manage that discussion. Not enough lubricant? Try some Astroglide!

If the discussion involves a selfish lover/partner, then what is newFNP to do? There are no Dr. Ruths in newFNP's clinic and there are probably no Dra. Ruths on Telemundo. Sadly, there is no wonder female sexuality duo a la Berman & Berman.

But mostly, there is no time.

So what is newFNP to do when her 40-something year old first time patient, all undressed in anticipation for her pap, lets newFNP know that she just never has orgasms. For all her life, no orgasm. Sex feels good, but there is just something missing.

And how!!!

Now, newFNP knows that this woman is looking for direction but - hell - newFNP is not her best girlfriend. She is newFNP! Can newFNP just say, "Listen. Seriously listen. You must teach your man how to perform oral sex. Period. At the very least, you guys should watch some Sex and The City reruns for inspiration."

It's a delicate topic, is it not? How does newFNP know if her patient is open to, say, the cowgirl position or assisted orgasm technology? They simply do not teach that kind of shit in multiculturalism workshops!

NewFNP didn't say what she may have said to a member of her grad school girl gang, but did bring up some options: communicate with your partner about what feels good; explore for yourself what feels good; maybe try a new position or two; and if all else fails, follow Charlotte York's lead and buy the Rabbit and call it a day.

This blog is for new NPs or NP students who want some real 411 on the life of a new practitioner. A new practitioner in a busy, understaffed, urban community health clinic in a major metropolitan area. Oh, and newFNP swears while writing and, sometimes, while working although she tries to keep those swears to herself. Consider yourself warned.